To persons completing this application:

Transcription

1 To persons completing this application: Thank you for your interest in the Toronto Rehabilitation Institute s Augmentative and Alternative Communication (AAC) Clinic. Who we see: Our mandate is to help adults with acquired disorders communicate to the best of their abilities. We see individuals who have difficulty with face to face communication. We also provide adapted computer access services to individuals who have physical limitations that affect their ability to use a regular keyboard and/or mouse. We do not have any geographic restrictions, but the applicant must be able to come to the clinic or have access to videoconferencing for the initial assessment. If seen via videoconferencing, the shipping costs of assessment equipment to and from the video suite, will not be arranged or paid by Toronto Rehab. What we do: As an Expanded Level Clinic designated by the Ministry of Health Assistive Devices Program (ADP), we can provide the following: Comprehensive assessment Prescription of voice output and writing aid equipment Training and support as appropriate Fees: There is no charge for the assessment, prescription or initial training. If the ADP eligibility criteria are met, the applicant can access the Ministry of Health s rental or purchasing assistance program for communication devices. Any remaining costs are the responsibility of the applicant. If ADP ineligible, the applicant, family or a third party is financially responsible for the purchase of the communication system. The Application Process: There are two requirements to the application process. 1. Fill out this application form (pages 2 to 6) as completely and accurately as possible, to assist us in preparing for the assessment process. All fields on Page 2 must be completed. 2. A written referral is required from a physician or a nurse practitioner for AAC Assessment/Service (a form is included on page 7 of this application if required). Both parts MUST be completed and received at the same time in order to process the application incomplete forms will be returned to the sender. Once the application and Doctor s referral have been completed, mail or fax them to the Augmentative and Alternative Communication (AAC) Clinic: Toronto Rehabilitation Institute, AAC Clinic E. W. Bickle Centre for Complex Continuing Care 130 Dunn Avenue Toronto, Ontario M6K 2R7 Fax: If you have any questions, please contact us at

2 GENERAL INFORMATION All fields on this page MUST be completed unless specified for application to be accepted Name of Applicant: # Street Apt City Postal code Phone #: (work) x. (Home): (optional): Medical Diagnosis: Date of Onset: Physician Name: Physician Phone #: Date of Birth: Health Card #: Day/ Month/ Year Primary Language: Other Languages: Gender (M/F): Marital Status: Citizenship: AAC needs (please check applicable): Face to Face Communication (difficulty speaking or being understood) Adapted computer access for basic writing Other: Contact Person: Relationship: Contact Phone # (work): x. (home): (optional): Next of Kin: Relationship: Phone #: Who initiated this referral? Relationship to applicant? Phone #: Person completing application form: Phone #: 2

3 Does the applicant receive: Ontario Disability Support (ODSP) Private Insurance (company) Ontario Works Support (OW) WSIB Veterans A: B: Other, Specify: Has the applicant received AAC services? No: Yes, when: Where? Vision: Circle the smallest letter the applicant can see at 40cm/16in (with glasses if required): N N N N N N Uses glasses: No Yes Describe: Visual Deficits: No Yes Describe: Other (e.g. cataracts, colour blindness, perceptual problems): Hearing: Difficulties Hearing: No Yes Describe: Cognition: Does the client have any difficulties with: Memory Problem solving Attention Learning new information Initiation Behaviour Mobility: Does the client use a wheelchair? No Yes If yes, please specify make: Describe any special equipment used to independently control TV, radio, lights, etc.: Physical: Can the applicant reliably control the movements of: No Yes Right hand Which was the Left hand dominant hand? Turn head Facial movements Which hand is used now? Eye blinks or gaze Leg or foot Other (e.g. breathing) Which movement is the most reliable and comfortable? Does the applicant have problems with fatigue? Describe: 3

4 FACE TO FACE COMMUNICATION To be completed only by applicants seeking assessment for a face to face communication aid. Comprehension Answering yes/no questions: % correct Following 1 step commands: % correct Following multi-step commands: % correct Expression Describe how yes/no is indicated (e.g. head nodding, speech): Speech/talking: % of speech understood by familiar listeners: Gestures (describe): % of speech understood by unfamiliar listeners: AAC system: describe any displays or devices used by the applicant and if they are currently in use: Symbol/Reading comprehension: Check if the applicant is able to understand: Pictures Single words Sentences Paragraphs Writing: Check if the applicant is able to write, either by hand or computer: Initial letters Familiar words Word/short phrases Paragraph Copying Has the applicant been assessed/ treated by a speech language pathologist (SLP)? Has the applicant been assessed/ treated by an occupational therapist? Yes Yes No No SLP s name: OT s name: Phone Number: 4

5 5 WRITTEN COMMUNICATION INFORMATION To be completed only by applicants seeking assessment for adapted computer access for basic writing. What are the writing needs? Please describe what kinds of things would be written, how frequently and for what reason: Describe problems with handwriting (eg. legibility, pain, speed, fatigue): Describe any problems using the computer: Any concerns with literacy? Does the applicant have difficulties with: Spelling If checked, describe: Reading If checked, describe: Previous computer experience or knowledge (provide more detail, where possible): Type of computer: Word processing software: Internet: Other software used: Type of adaptations (switches, keyboards) Other: Does the applicant own a computer system (include age): IBM compatible, describe: MacIntosh, describe: Other, describe: Has the applicant been assessed/ treated by an occupational therapist? Yes No OT s name:

6 FACILITATOR INFORMATION To be completed by all applicants A facilitator is an individual(s) who will take responsibility to support the use of the AAC user s communication system. This could be a spouse, family member, caregiver or healthcare professional. It should be someone who interacts with the users regularly on a long term basis. A facilitator will: 1. Attend the assessment sessions(s) if possible. 2. Support the maintenance of the system or device. 3. Serve as a contact person between the Toronto Rehab AAC clinic and the client. 4. Assist with the equipment transportation between the client and the clinic. Individuals who are non-speaking will need a facilitator. Individuals who are verbal and seeking assessment for written communication do not require a facilitator although it is strongly recommended, especially if the individual is physically unable to setup and transport equipment on their own. Facilitator name(s): Agency (if applicable): Postal Code: Telephone Number: (home): (work): X: Relationship to AAC user: How much time do you spend with the applicant on an average week (in hours)? FACILITATOR COMMITMENT: I agree to act as the facilitator for the client described above and I accept the responsibilities as outlined. Signature Date 6

7 REFERRAL FORM FOR AUGMENTATIVE AND ALTERNATIVE COMMUNICATION (AAC) CLINIC SERVICES Toronto Rehabilitation Institute, AAC Clinic E. W. Bickle Centre for Complex Continuing Care 130 Dunn Ave, Toronto, ON M6K 2R7 P: F: Your physician or nurse practitioner may send in their own referral form if preferred. All the fields in the Referral Source section must be included for the application to be considered complete. Referral Source (all fields must be completed): Date of referral: Physician or Nurse Practitioner name: # Street City Postal code Fax Number: Patient Details: Patients name: Diagnosis: Reason for Referral: I am referring the above named patient to the AAC clinic for a communication assessment as he/she is having difficulty with: Face to face communication Computer access for basic writing Both face to face and computer access Other (specify) - I would like a summary report: Yes No Comments: Physician/Nurse Practitioner Signature: 7